Plans on the road toward a national information exchange

When it comes to electronic patient information, the healthcare industry is still learning how to share. Federal regulations, grant money and incentives have hastened the construction of various segments of the infrastructure needed for a national health information data exchange, but none are complete. Rather than a linear effort to collect data, create standards to govern its use, and then build the networks stakeholders need to communicate, there is simultaneous activity on all fronts.

“It’s like we have a set of towns across the country and no roads between them,” says Jennifer Covich, CEO of eHealth Initiative, an organization that engages healthcare stakeholders to standardize and reform the use of health information technology. “We’re building more towns before we build the roads. A hospital could have a very sophisticated IT system, but it doesn’t matter unless you’re in that ‘town.’”

Data Collection Efforts

As those “roads” are built, there are bound to be bumps along the way. However, the goal of a national network capable of sharing health information continues to advance, starting with data collection.   

“There has been significant progress,” says Covich. “We don’t have to convince people that EHRs are important. Everyone knows it’s needed, they just want to know how to implement it. We have doctors and hospitals and health plans collecting data, now we just need to move it and use it.” 

It wasn’t that long ago when there weren’t any electronic health records to share. Thanks in part to financial incentives for the meaningful use of certified EHR technology, basic electronic health records have been adopted by about half of office-based physicians, according to the National Center for Health Statistics (NCHS) at the Department of Health and Human Services. “Basic” means they have met some, but not all meaningful-use requirements. The 2013 adoption rate for basic EHR was 48.1%, compared to just 10.5% in 2006. While half of doctors meeting some requirements may not sound that impressive, consider that in 2013, 78% of office-based physicians used some type of EHR system, up from 18% in 2001, according to NCHS.

Standardization is Underway

Moving and using healthcare data requires standards, agreements on what type of data is important, and with whom it should be shared. Enter the Nationwide Health Information Network in 2007, which, despite its name was not a network. It was a framework for a set of standards, services, and policies funded by the Office of the National Coordinator for Health Information Technology (ONC) that was intended to enable the secure exchange of online health information. Those standards formed the basis of meaningful use objectives. The Nationwide Health Information Network is now referred to as the eHealth Exchange, which describes itself as a community of providers and patients that is sharing health information via the operational support of Healtheway, a non-profit, public-private collaborative.

“Specifications are tight, and security issues and accreditation are strong,” says A. John Blair, III, MD. He served on ONC's Nationwide Health Information Network committee and its Privacy and Security Workgroup.

Dr. Blair is also chief executive officer of the Hudson Valley Initiative, an organization created to improve quality, safety and efficiency of healthcare in the Hudson Valley through the use of health information technology and improved care delivery models. Six commercial health plans are part of the initiative.

He says the sharing of EHRs takes two forms: pull and push. The pull scenario relies on a shared repository of EHR information that qualified stakeholders can query to obtain the information they need. The push method, also known as direct exchange, allows clinicians to share specific patient information directly with one another.

Interoperability Challenges

State health information exchanges (HIEs) and many of the regional exchanges and consortiums are primarily query-based, says Dr. Blair.

“To some degree they all make up some piece of a future national network,” he says. “Healtheway is an umbrella organization that begins to connect all of them. It’s patching together these traditional HIEs.”

He compares the direct exchange model to cellular networks like those operated by Verizon, AT&T or Sprint. Users of one provider can still talk to each other, he says. Similarly, if a patient’s primary care physician is on one direct exchange network and his specialist is on another, they should still be able to communicate health information electronically.

That’s the significant challenge to a future national health exchange: interoperability.

“As a technologist and health professional, I would describe the investments being made toward healthcare information exchange as necessary but not sufficient,” says Mark Boxer, global chief information officer for Cigna. “We are laying the groundwork, but we’re not there yet. There’s a lot of heavy lifting to be done.”

He says interoperability efforts so far have been focused on systems that are highly vertical.

“They’re integrated, but on a closed basis,” he says. “They’ve proven the theory, but have not accomplished the need to connect disparate systems across geographies.”

Paul Oates, senior director of Enterprise Architecture for Cigna agrees. He says vertical organizations including the U.S. Department of Defense and the U.S. Department of Veteran Affairs, especially, have advanced the cause via Healtheway.

“Now we want to move into ubiquitous data sharing where we can move data one patient at a time, share information about groups of patients and allow consumers to access their information electronically,” he says.

Collaborative Healthcare

The ability to share health information electronically is critical to the goal of improving quality of care while reducing costs, which Boxer says is being proven out via accountable care organizations (ACOs). 

“I think in many ways, ACOs are going to be a catalyst of change in data sharing,” he says. “For a volume-to-value model to take hold, stakeholders need access to data in order to make a collaborative care model work effectively.”

The analytics that allow ACOs to measure their effectiveness - from quality of care to cost to patient satisfaction - all depend on collecting and sharing data.

“Look at movement around value-based purchasing,” Dr. Blair says. “If you start to dissect it out, analytics is clearly very important. HIEs will have a role in providing community-wide data to help you understand behavior. Also very important is your transition of care.”

That’s why Oates and Boxer both say they are optimistic about the future of healthcare data exchange.

“Today the standards are focused on moving data between physicians,” Oates says. “But there is other information, such as what are my gaps in care, who is my health coach, what are my goals and aspirations to improve my health? Those don’t exist today. We need that for 360-degree view of health information.”

Boxer says stats around EHR adoption, the progress around vertical exchanges, the work toward standards put the healthcare system on the cusp of “something big,” especially with the progress with in ACO model.